NURSING CARE FOR Mrs.

M
WITH PAIN RELIEF
IN THE TERATAI ROOM OF SUNAN KALIJAGA HOSPITAL IN DEMAK

Arranged by;
NAMA : Tri Wahyu Yulianti
NIM : P1337420417006
KELAS : 2B
Case.
Mrs.M the age of 26 years, female gender, address of the Tambak Roto, Demak. Come to Sunan Kalijaga
General Hospital Demak on November 6, 2018 with complaints of pain, weakness, nausea and vomiting.
Physical examination found BP : 150/90 mmHg, PR: 105 x / minute, RR 28 x / minute, T: 38'C

A. assessment
student name : Tri wahyu yulianti
place of practice : Sunan Kalijaga General Hospital Demak.
Practice Date : October 29, 2018
1. Biodata

Name : Mrs.M

Age / date of birth : 26 years / 10 June 1992

Job : housewife

Education : mts

Female : Gender

Religion : Islam

Mental Status : Composmentis

Address :Tambak Roto, Demak

no. register : G01200073937 Person in charge

Name : Mr.A
Age : 28 years
Job : Entrepreneur
Address :Tambak Roto, Sayung, Demak.
Relationship with clients : husband
2. Main Complaints.
The patient says pain in the lower right abdomen of nausea, vomiting, and weakness
3. current disease history
On November 6, 2018 the patient was taken to the IGD of the Sunan Kalijaga Hospital Demak.
Patients complain of lower right abdominal pain, nausea, anxiety and vomiting. The patient's meeting
is below to the lotus room for further examination.
4. Health history first.
The patient said before she checked her doctor with a medical diagnosis of appendicitis and had never
arrived at surabdomen. Patient also said that he did not have food or drug allergies.
5. family health history
The patient said that none of his family had the same disease as the disease currently
suffered.
6. Physical examination
General condition: weak, restless, pale Vital sign :
Appearance : fat Blood Pressure : 150 / 90mmHg
Awareness : Composmetris Pulse rate : 105x / minute
Height / weight : 160cm / 87kg Respiration : 28 x / minute
Temperature : 38'C
Head Ear
The form of ignorance : Mesochepal Clean
Hair : Short hair Inflammation : Nothing
Scalp : Clean hearing function : Normal

Eye Mouth
Inflammation : no Lips : Pale, slightly broken
Sklera : Not jaundice Teeth : Clean
Conjunctiva : Not Anemic Tongue : Clean, no lesions
Pupil : No interference. Inflammation : Nothing
Talk function : Normal
Nose
Polyps : None Neck
Bleeding : None Enlargement of the thyroid gland : None
olfactory function : Normal Stiff neck : None
chest (lung)
Inspection : symmetrical, no operation
marks
Abdomen
Palpation : no lumps
Inspection : The abdomen is slightly distended, there is
Percussion : sonor no trace of surgery
Auscultation : ronchi lung sounds Auscultation : Bowel sounds decrease 5 times / minute
Palpation : Lower right tenderness, hard abdominal
heart palpation on the lower right

inspection : symmetrical Percussion : There is a period in the lower right

abdomen
palpation : no lumps, and chest pain
percussion : compensated
auscultation : Heart sounds 1 and 2 Regular
Patterns of daily life

a. Feed / nutrition patterns

Before getting sick : Patient eats 3x a serving once a day
During illness : Patient says eating 3x a portion is finished, tai after eating always
feels nauseous.
b. pattern of rest and sleep
Before illness : Patients say sleep + - 8 hours a day
During illness : Patients say it is difficult to sleep and often wake up at night
c. CHAPTER BAK
Before illness : Patients do not believe in BAK or BAB disorders, BAK patients every
day 4 to 5 x / day and BAB 2 times a day
During illnesss : Patient says CHAPTER 3x / day and during illness has not reached
BAB
d. personal hyegine pattern
Before illnesss: Patient states taking a bath twice a day, shampooing every 2 days, and brushing his
teeth twice a day.
During illness : Patient says taking a bath one day, has never shampooed, brushed his teeth once a
day

e. pattern of activity and practice

Before illnesss : Patient is able to carry out daily activities without interruption
During illness : Patients are only able to rest, sleep and sit while other supporting activities such as
bathing and BAK are assisted by the family.
therapy

a. Infusion of RL 20 drops / minute

b. inject Ranitidine 2x1 amp. IV
c. Ondancetron injection 3x1 amp.IV
d. @ inc 1x1 tab
e. New Diatab, tab 3x1
9. investigation
a. X-ray examination
b. laboratory examination
routine hematology resuvalue reference value
Hemoglobin 16.3 11,7-15,5
Hematocrit 37,2 35-47
Leukocytes 11,8 3,6-11,0
Platelets 427 150-400
Erythrocytes 4,31 4,0-8,0
Neutrophils 47,3 50-70
Lymphocytes 37,5 25-40
Monocytes 8,4 2-6
Eosinophils 6,6 2-4
Basophils 0,2 0-1
MCH 28,5 26-34
MCHC 33,1 32-36
MCV 86,3 80-100
RDW 13,2 11,5-14,5
MPV 9,6 6,8-10,0
PDDW 10,3 10,0-16,0
 B. Analysis
Data focus etiology problem Signatur
e
DS: Inflammation Pain Relief ɸ
-Patient says stomach hurts in the lower appendix
right
-Patient says often nauseous and
sometimes vomits
-Patient said body felt weak because
she aching and vomiting
DO:
-Patient looks weak and pale
Blood Pressure : 150 / 90mmHg
Pulse rate : 105x / minute
Respiration : 28 x / minute
Temperature : 38'C
-Patient looked wincing in pain
 C. Nursing Diagnoses

Discomfort in pain is associated with inflammation of the appendix characterized by

lower right abdominal pain
THANK YOU